Take Home Message: Following
removal of immobilization, a patient recovering from an isolated uncomplicated
ankle fracture does not benefit more from a supervised exercise program and
advice compared with advice alone.

Despite ankle fractures being common, we don’t
know the best rehabilitation strategy after a surgery and/or immobilization.
Therefore, the authors investigated the effectiveness and cost-effectiveness of
a supervised exercise program with advice about self-management (rehabilitation)
compared with advice alone among individuals with an isolated ankle fracture.
Additionally, the authors evaluated whether differences between groups were influenced
by fracture severity, sex, or age. Two hundred and fourteen participants who completed
skeletal growth (94 men, 120 women) were randomized into the rehabilitation
group (106 participants) or the advice-alone group (108 participants). A
physical therapist provided the advice-only group with one informational
session about exercise (non-weight-bearing ankle positions) and return-to-play
activity. The advice-only group also received a handout summarizing the advice
with illustrations. Participants in the rehabilitation group received the same
advice in addition to participating in a supervised exercise program tailored,
monitored, and progressed by a physical therapist. Participants in the
rehabilitation group performed ankle mobility and strengthening exercises,
weight bearing and balance, and stepping exercises with supervision (1-2
times/week for 4 weeks). They were also encouraged to perform these exercises at
home. Participants completed the Lower Extremity Functional Scale (0-80; higher score better activity) and Assessment of Quality of Life (0-1; higher score better quality of life) at baseline
(prior to randomization) and at 1, 3, and 6 months post advice session. Cost
was measured in terms of direct costs to the health system and out of pocket
costs to the participant over 6 months. Participants were ~42 years of age on
average. The rehabilitation group did not improve more than the advice only
group in self-reported function or quality of life. Treatment effects were not influenced
by fracture severity, age, or sex. The authors skipped the full cost analysis;
however, the rehabilitation group had a higher cost to the health care system,
but there were no differences between groups for out-of-pocket or total costs.

The
authors demonstrated that a supervised exercise program with self-management
advice did not improve activity limitation or quality of life more than a
one-time information session. Furthermore, fracture severity, age, or sex of
the participant did not affect the outcome. Unfortunately, the authors did not
explore if the level of occupational or recreational physical activity
influenced the outcomes. These results may be applicable to the general
population we see in our clinics, but it is unclear if they would apply to
individuals who perform more physically demanding tasks (for example, athletes
or construction workers). It was also interesting to note that there were no
differences between out-of-pockets costs between groups; however, it was more
costly to the health care system. Based on this study, medical professionals
should be aware that routine care for those recovering from isolated,
uncomplicated ankle fractures should include self-management advice at the time
of removal of immobilization and supervised exercise may not be necessary for
most patients.

Questions for Discussion:
Do you think there would be a difference between groups long term (1+ year)?
What advice do you provide your athletes about home exercise? What are your
concerns about home exercise programs?

2
comments:

John J Fraser, PT, MS, OCS
said...

Dr McDevitt, thank you for the review of this paper. In response to your first discussion question, it is unclear whether there would be differences at one year based on the outcome measures utilized by the authors. In this study, the authors relied solely on patient reported measures of function and quality of life and did not collect any objective clinical measures such as ankle range of motion. It is plausible that impaired ankle dorsiflexion not addressed in the short term due to assignment to the home exercise program (HEP) group could manifest as a musculoskeletal injury in the long term.

Patient compliance is my primary concern when prescribing a HEP. In a systematic review of adherence to HEP in patients with chronic low back pain, Breinart and colleagues (2013, Spine J) reported that patients who had higher loci of control and that were supervised, received positive feedback, and engaged in an exercise program were subfactors of compliance. When advising patients on HEP, I typically limit the number of exercises to no more than 3-4 to minimize time commitment and have the patient perform the exercises 3/day. I have the patient return at regular intervals to ensure that they are performing the exercises using appropriate technique, which also allows me to assess compliance and offer ongoing positive feedback.

John, Thank you for your response. I agree that due to the lack of objective data it would be hard to determine if long term problems would arise, which was my concern. I think that limiting the number of exercises to 3-4 is a great idea, and even better to have them return on assess they are continuing to use proper technique and complying the program.

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